What are the experiences of women at war, and what to tell clinicians about how to help? I have been asked to write a textbook on this subject, so have done another canvass of the literature.

What is striking is how little hard data there are about the experiences of female Soldiers and other service members from the wars in Iraq and Afghanistan.

There are lots of articles published by Department of Veterans Affairs authors about the experience of female veterans from earlier conflicts. These normally focus on PTSD and sexual assault. There are some very poignant newspaper articles about the struggles and triumphs of individual female service members and recent veterans.

But the scientific literature is sparse when it comes to the experiences of women who are still serving in the military. The research in the Army has focused on combat teams, who, by definition, are male. A few exceptions: the second Mental Health Advisory Team (MHAT-II) did survey enough women in 2005 to draw some conclusions. Its authors found that the rate of PTSD and related symptoms was very close to, and slightly less than, those of men (12% vs. 13%). MHAT VI had similar findings.

But that’s about it for scientific research, despite the fact that the military has been about 15% female for many years.

The public conversation about women in the military has all been about sexual assault and whether they should be in combat. These are important issues, but the predominant challenges that female service members face are trying to balance deployment with gynecological, reproductive, and family issues. I published on this very topic in 2001 in Military Medicine. Unfortunately not enough has changed.

It makes the men uncomfortable when I say this: how do you change your tampons while driving across the desert in a tank?

If on a convoy, women tend to not drink water, as they have no safe place to pee on the side of the road. This often leads to urinary tract infections.

Often there are only a couple of porta-potties for women. During my time in Somalia, if the “local” female toilet was being cleaned (eg contents of the oil barrel being burned), I had to walk 20 minutes to another female latrine.

Porta-potties have improved over time, as the infrastructure has improved. Except in remote outposts.

More dispiriting is this comment, from Dr. Remington Nevin, a military preventive medicine physician who served for a year at headquarters level in Afghanistan:

My experience in Afghanistan was that pregnant females were disproportionately the targets of punishment from no-sex policies. There were widespread anecdotal reports of medically unsupervised abortifacient use. Plan B was not routinely made available as an Over The Counter medication, and there was a grave reluctance to seek care for sexually transmitted infections (STI) and military sexual trauma (MST). Our Preventive Medicine section was chastised for distributing condoms. It was all very Victorian and quite unhealthful and very disheartening.

For women who have given birth, another major concern is how to maintain breast-feeding in unsanitary places, such as field exercises. The Canadian military allows women a year after birth before deploying. In the U.S. Army, the deployment-free period has gone from four to six months. Not much more has changed in the last eleven years.

Balancing family and work while on exercises or deployment is a huge issue. Of course this includes raising children, but it also involves caring for elderly parents and other family members. Almost all of my female contemporaries in military medicine who had children got out of the service shortly afterwards.

There have been advances. The public conversation is no longer whether women should be in the military at all. There is widespread recognition that women are in combat, whether or not they are in a combat job. For better or worse, when a woman is wounded or killed, there is not a public outcry.

The military could do far more, and it is trying. There is a task force on woman’s health issues. But I have observed many times, both during my time on active duty, and since retirement, that the military changes when the media, the Congress and the American people, push them.

Exhibit A: the recent no-fuss repeal of “Don’t Ask, Don’t Tell.”

So, it’s up to you, Jane and Joe American Public: push the military to be more accommodating for your daughters, wives, sisters and aunts who are heading off to war. After all, just like their brothers in arms, they are willing to make the ultimate sacrifice for the rest of us.